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BACKGROUND

Management of Depression in Primary Care Dr Carole McIlrath Senior Professional Officer Northern Ireland Practice & Education Council. BACKGROUND. DEPRESSION. many mood disorders with varying severity, symptoms and persistence

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BACKGROUND

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  1. Management of Depression in Primary CareDr Carole McIlrathSenior Professional OfficerNorthern Ireland Practice & Education Council

  2. BACKGROUND

  3. DEPRESSION • many mood disorders with varying severity, symptoms and persistence • dysthymia, major depressive disorder, bipolar disorder, psychotic depression, post-partum depression & seasonal affective disorder • leading cause of disability worldwide (121 million) • 70% of recorded suicides • psychiatric disorder 90% of suicide victims

  4. INCIDENCE • Taiwan - 0.8 cases per 100 adults • 5.8 - New Zealand • 6% - Australia • 5% - 10% - UK • 10% - USA • 23.5% - Japan

  5. NORTHERN IRELAND • 21% aged over 16 • 24% women & 17% men • mental health needs 25%  than England • Prescriptions – • anti-depressants 37% , • psychosis & related disorders 66%  • hypnotics & anxiolytics 75% 

  6. CO-MORBIDITY • cancers • 4.5% to 58% • cardiovascular disorders • myocardial infarction 20-30% • chronic conditions • asthma & diabetes – 50% • neurological disorders • Parkinson’s Disease 40-50% • Stoke 16-60% • GPs – three times more likely to miss major depression in minor physical illness & five times more likely to miss major depression in serious physical illness

  7. POLICY CONTEXT • increasing recognition of mental illness • major public health issue • emphasis on promotion of mental & emotional health • 30 years refocusing of service provision away from hospital settings towards community care • Greater understanding of mental illnesses • developments in psychopharmacology • changes in social policy • vast array of legislative change • Sex Discrimination Act 1975; Race Relations Act, 1976; Mental Health Act, 1983; Disabled Persons Act, 1999; NHS & Community Care Act, 1990

  8. PRIMARY CARE early 1990s - the development of primary care support mental health services improve collaboration between secondary care & primary care professionals potential for early detection, intervention, utilisation of voluntary sector organisations and mental health promotion to support this - NSF for Mental Health set national standards and defined service models seven standards - first three relevant to and promote the development of primary care mental health services NI has lagged significantly behind developments

  9. NORTHERN IRELAND • regional strategic objectives highlighted mental health as a priority for action: • Health and Well-Being into the Millennium (97-02) • Health and Social Well Being Survey (02) • Programme for Government (NIE, 02) • Investing for Health Strategy (02) • Promoting Mental Health Strategy & Action Plan (03) • Bamford Review of Mental Health (05 &06) • “each individual with a mental health problem should be given the opportunity to have their mental health needs understood and addressed promptly within primary care settings, taking into account biological, psychological and social dimensions”

  10. PRIMARY CARE “It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process” (WHO, 1978)

  11. Membership of the primary care team

  12. Almost 20,000 people actively involved in the provision of primary care services: • 1,200 GPs; • 5,000 Nurses; • 250 Midwives; • 700 Dentists; • 1,000 Community Pharmacists; • 1,000 Allied Health Professionals; • 500 Optometrists; • 4,000 Social Workers; and • 6,000 Home-helps. Source: DHSSPS (2005)

  13. PRIMARY CARE  90% cared for and managed  50% of attendees from depression patients present with  somatised medical problems nearly three times the consultation rates  suicide link variations 50% ‘missed’  10% spent

  14. PROFESSIONAL ISSUES Primary care nurses increasingly involved in identifying, assessing and caring for people with depression: little time allocated often untrained & unsupported CMHNs - “mild” or “moderate” mental illness widely accepted in April 1993 - GP fund-holders CMHNs well regarded many GPs favour closer liaison much criticism however at risk of abandoning most vulnerable – SMI little attention paid to their selection & preparation many torn between the demands of GPs and their employing Trust

  15. RESEARCH • Recommendations from: • Bamford Review of MH & LD (DHSSPS, 2005) • New GP Contract (BMA & NHS Confederation, 2004) • ideal vehicles for developing primary care depression services, some nurse-led. • Nonetheless, • clarity of roles & responsibilities • gaps in the knowledge & training of primary care nurses • no consensus on what standards, guidelines or benchmarks constitute an effective primary care based nursing service for adults with depression. • develop, support and guide their practice • benchmark – a standard to judge or measure something against

  16. Research Questions 1. What are the most appropriate benchmarks for an effective primary care based nursing service for adults (18-64 years) with depression? 2. To what extent do existing primary care based nursing services for adults with depression in Northern Ireland conform to these benchmarks? 3. What are the best strategies for enhancing existing primary care based nursing services for adults with depression?

  17. Design & Methodology Exploratory survey design Qualitative approach multiple methods Two phases Ethical Issues

  18. Phase One Delphi technique Purposive Sampling Inclusion criteria 84 potential experts 67 (80%) Mental Health Nurses (n=36) Health Visitors (n=9) Practice Nurses (n=2) GPs (n=16) Psychiatrists (n=4)

  19. Pilot Study • Questionnaire • Content and face validity • 10 professionals • 100% response • Minor adjustments • Layout • Design • Content

  20. Findings • Round One Questionnaire • 96% response rate • 53% post / 47% email • 1216 statements • 239 benchmarks • 3 categories

  21. Benchmarks Structures – 126 • a primary care based depression service should support and utilise guidelines which have been modified for local circumstances (NICE) • protected time should be provided to primary care practitioners to manage depression, attend reviews, supervision sessions and education programmes related to depression services • all practice nurses should have attended at least a one day training course on depression

  22. Benchmarks Processes – 70 • Structured assessments should be completed by primary care practitioners using validated rating scales to diagnose depression (PHQ-9, HADS, EPNS) • Clients with depression should have access to and choice of a range of support/treatments following a clear stepped care model • Interventions provided in primary care should be structured, time limited, evidenced based and adapted for use in a busy primary care setting (CBT)

  23. Benchmarks Outcomes – 43 • There should be an increase in the number of primary care nurses with the training and skills to assist in the management of clients with depression • There should be a reduction in the amount of time clients with depression have to wait for psychotherapeutic interventions • There should be a reduction in the number of episodes of relapse of depression

  24. Round Two Questionnaire • 95% response rate • 26% post / 74% email • consensus 70% • descriptive statistics • 22 benchmarks

  25. Round Three Questionnaire • 95% response rate • 10% post / 90% email • consensus 70% • descriptive statistics • consensus - 22 + 51 benchmarks • 45 (61%) structures • 18 (25%) processes • 10 (14%) outcomes

  26. PHASE TWO • Multiple Methods - triangulation • Interviews • Observation • Document analysis • Stratified purposive • Content Analysis

  27. BENCHMARKING TOOLKIT • Practice Manager

  28. BENCHMARKING TOOLKIT • GPs, Nurses, Health Visitors

  29. FINDINGS • 42 primary care professionals • eight primary care practices • 2 from each of the Board areas. • This included • GPs (n=8), practice managers (n=8), practice nurses (n=8), nurse practitioners (n=2), health visitors (n=8) & CMHNs (n=8)

  30. Primary care nurses view the provision of depression care as part of their role: • all practice nurses (87.5%, n=7) and one nurse practitioner (50%) reported that they provided a limited role in the care of patients with depression and did not view further depression care as part of their current role • These views reflected the responses from three quarters of the GPs (n=6) interviewed. They also viewed practice nurses and nurse practitioners as having a limited role in the care of patients with depression. They suggested that mental health nursing services should be provided by the Trusts rather that GPs. • Potential barriers perceived by practice nurses and nurse practitioners preventing greater involvement in depression care included insufficient time (70%, n=7); a lack of knowledge and confidence (70%, n=7) and a lack of GP support (80%, n=8).

  31. There are adequate levels of primary care nurses to enable effective involvement in depression services: • Three quarters of health visitors (n=6) reported that they felt current levels were inadequate to deal with post natal depression due to current work pressures. • All practice nurses (n=8) and nurse practitioners (n=2) interviewed reported inadequate numbers to enable them to take on new roles in depression care. • All CMHNs (n=8) suggested that current levels of primary care nurses were inadequate to deal with the high prevalence of depression in primary care. Six (75%) CMHNs indicated that they were being referred patients with less serious levels of depression who they thought should be managed by practice nurses. Five (62.5%) reported that more CMHNs or mental health nurses dedicated to primary care were needed to ensure patients were treated as early as possible following a diagnosis of depression. Concerns were expressed relating to a possible dilution of the CMHN role and diversion of resources for the care of people with severe mental illness due to the demands of a group of people described as less seriously ill.

  32. Alternative service delivery models are used by primary care nurses to support patients with depression: Most practice nurses (75%, n=6) and all nurses practitioners (n=2) interviewed referred to face-to-face consultations at the practice. Services provided within these consultations included, health promotion, basic screening, provision of information and advice and referral to the GP for follow up if appropriate. The two practice nurses (25%) reported using telephone follow up, but this was only provided occasionally. Six (75%) CMHNs reported that their main method of service delivery involved outpatient appointments or home visits. However, the CMHN attached to primary care and one other CMHN, who was employed by a community mental health trust, reported that they provided mental health triage as an alternative method of service delivery.

  33. The main barriers perceived by participants preventing the use of alternative service delivery models include the following: a lack of opportunity for primary care nurses to be involved in depression care (26.9% n=7); a lack of knowledge of available models (69.2%, n=18); funding and resources to lead and develop new models within primary care (80.7%, n=21); support from GPs and managers (88.4%, n=23); and a lack of relevant personnel to supervise specific programmes, for example, computer based therapy programmes (46.1%, n=12).

  34. Primary care nurses are able to carry out a basic assessment to detect depression • Primary care nurses have knowledge of the causes, symptoms of depression and influences of co-morbidity • Primary care nurses have knowledge of relevant local statutory, voluntary and private services for patients with depression • Primary care nurses have knowledge of local guidelines/protocols for drug treatments and therapeutic doses/side effects

  35. Primary care nurses are competent at assessing suicide risk • Primary care nurses have an identified level of depression training and competency • There is regular continuous professional development (CPD) for primary care nurses on the recognition and management of depression • most practice nurses (87.5%, n=7), nurse practitioners (100%, n=2), health visitors (63%, n=5) and CMHNs (75%, n=6) reported a lack of regular CPD on the recognition and management of depression. Barriers identified included lack of time, support from management and availability of courses.

  36. Protocols for the recognition, treatment, management and referral of patients with depression are used by primary care nurses

  37. A range of evidence based treatment interventions are provided by primary care nurses to patients with depression • Three quarters of practice nurses (n=6) and all nurse practitioners (n=2) saw their most important treatment intervention as listening to patients and letting them discuss their worries or problems. The other relevant treatment interventions most commonly reported included basic counselling (40%, n=4) and referral to the GP (90%, n=9). • The treatment interventions CMHNs reported using included case management (62.5%, n=5); marital, bereavement and general counselling (75%, n=6); psychosocial interventions (50%, n=4); anxiety management (50%, n=4) and CBT (25%, n=2).

  38. Summary of benchmarks met by each practice

  39. Recommendations • Investment/enhanced • Priority • Primary care team/lead • All practitioners • Early intervention • Training/time • Partnerships/protocols

  40. SERVICE MODEL

  41. NEW MODEL

  42. Contact Details • carole.mcilrath@nipec.n-i.nhs.uk • 028 90238152

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